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In the Hamm Alert Maritime Safety Act of 2018, as part of the Save Our Seas Act of 2018, Congress required the U.S. Coast Guard (Coast Guard) to sponsor an independent assessment of the effectiveness of its oversight of recognized organizations (ROs) and the impact on vessel compliance and safety. In responding to this mandate, the Coast Guard commissioned this study by an expert committee to review the Coast Guardâs ongoing and planned efforts to âoversee, guide, monitor, assess, and otherwise strengthenâ the performance of ROs in carrying out their delegated inspec- tions and other statutory certifications and services. In formulating the Statement of Task for the study, the Coast Guard asked that consideration be given to changes that have been made in areas such as institutional and organizational structures; policies, and procedures; guidance and compli- ance documents; data and analytic systems; training; communications; and performance reporting. This chapter summarizes findings from the study committeeâs review in fulfillment of the Statement of Task. The summary follows the structure of the report. It first considers the Coast Guardâs accomplishments in creat- ing new and improved organizational structures, guidance, and procedures (as discussed in Chapter 3). It then presents the committeeâs findings and conclusions about the Coast Guardâs progress in developing needed data, analytic tools, and key performance indicators (KPIs) (see Chapter 4) and ensuring sufficient inspector resources, training; and coordination with ROs (see Chapter 5). When considered together, the recommendations from these chapters are indicative of the need for the Coast Guard to move 7 Building and Sustaining a Safety Partnership 121
122 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs beyond the initial stages of policy and program introduction to ensuring their increasingly effective, long-term execution. In having undertaken this requested review, the committee revisited the study request in the legislation and took note of Congressâs interest in ensuring that the Coast Guardâs oversight of ROs in performing their delegated functions not only brings about higher levels of regulatory com- pliance but also higher levels of safety. Safety, after all, is the end goal of regulation and the reason for emphasizing performance oversight. The El Faro tragedy that prompted Congress to act revealed not only short comings in the Coast Guardâs vigilance in overseeing the performance of the ROs but also in working with and supporting them to fulfill their delegated functions. In believing that the Coast Guard and ROs should view their relation ship as a safety partnership, the committee concludes the report with a recommendation emphasizing the importance of building and sus- taining that partnership through more than just monitoring and oversight but also by greater cooperation, better communication, more transparency, and leveraging continuous learning for improvement. ORGANIZATIONAL STRUCTURES, GUIDANCE, AND PROCEDURES The Hamm Alert Maritime Safety Act calls on the Coast Guard to create an office that will conduct comprehensive and targeted oversight of all ROs and that is staffed with subject-matter experts, including inspectors, investigators, and auditors, having the capability and authority to audit all aspects of ROs. The committee finds that the creation of such an oversight office, the Flag State Control Division (CVC-4), has been a central factor in the Coast Guardâs transformation from what had been an inconsistently followed and loosely integrated collection of policies and procedures into a deliberate and increasingly cohesive and comprehensive program for over- seeing RO performance. In having established an organizational unit with singular responsibility for third-party oversight, the Coast Guard is not likely to regress to complacency, as occurred during the Alternate Compli- ance Programâs (ACPâs) first 20 years when procedures to fully implement oversight policies did not materialize and key staffing positions such as the RO liaison officer were eliminated. The numerous accomplishments of the Coast Guard and CVC-4 are documented in this report. They include the creation of a civilian work- force of third-party organization (TPO) coordinators that has the author- ity and capability to conduct audits of ROs and observe and review the audits that ROs conduct of the safety management systems (SMSs) of ves- sels and vessel owners. CVC-4 is responsible for ensuring that the Coast Guardâs ACP policy, as contained in NVIC 02-95, is kept current, while
BUILDING AND SUSTAINING A SAFETY PARTNERSHIP 123 also providing guidance and procedures for inspectors and TPO coordina- tors on policy implementation. For such purposes, CVC-4 has introduced a set of work instructions for field inspectors for detecting, and referring to TPO coordinators, evidence of lapses in the quality of RO inspections and in their audits of vessel and company SMS plans. The work instruc- tions contain a well-defined process for triggering demands for an RO to conduct an internal audit of its quality management system (QMS) and for CVC-4 to audit the RO to confirm that the ROâs QMS is adequate and being followed. This report also points to areas where CVC-4 has made less progress than desirable. Perhaps most notably, it has not succeeded in developing insightful metrics on RO performance and in reporting them publicly. Some of the reasons for this lack of progress, as recounted below, stem from funda mental shortcomings in data and data systems that CVC-4 cannot resolve on its own. Training courses for field inspectors on the requirements of ACP and SMS and that are applicable to the kinds of vessels common to the ACP fleet (e.g., older and subject to a number of legacy standards) have been slow to materialize. CVC-4 has tried to compensate for these gaps through its own efforts to inform inspectors during annual conferences, but training of inspectors and other marine safety personnel is under the purview of other Coast Guard support units. Given its responsibility for flag-state control policies and RO oversight, the CVC-4 would be expected to spearhead mutually agreed to recommen- dations as set forth in this report. However, the study committee recognizes that the Coast Guardâs Prevention Program under the Deputy Commandant for Operations is large and includes multiple centers and offices having re- sponsibility for marine safety regulation and standards development, plan review, and accident investigation. In residing in the Prevention Programâs Office of Vessel Compliance, CVC-4 must function within this broader organizational structure, while also coordinating with and depending on other Prevention Program units (e.g., traveling inspectors, Marine Safety Center, Design and Engineering Standards) and Sector Commanders for support in carrying out responsibilities. It must also depend on Mission Support units such as Information Technology (IT) (to modernize vessel documentation, support data analytics, and provide digital tools), Human Resources (for marine safety workforce planning, recruiting, and retention), and Force Readiness (for marine inspector training, education, and assess- ments). For the Coast Guard to act on many of the recommendations in this report, the coordination and commitment of these many operational and support units will be crucial. Figure 7-1, which was presented earlier in Chapter 3, shows graphically how the Coast Guard has introduced many new RO oversight policies and procedures, most of them developed and implemented by the CVC-4 in
124 FI G U R E 7 -1 C oa st G ua rd a ct io ns i n re sp on se t o fin di ng s an d re co m m en da ti on s fr om E l Fa ro i nv es ti ga ti on s pe rt ai ni ng t o th e A lt er na te C om pl ia nc e Pr og ra m a nd t hi rd -p ar ty o ve rs ig ht . N O T E : A C P = A lt er na te C om pl ia nc e Pr og ra m ; C V C -4 = C oa st G ua rd F la g St at e C on tr ol D iv is io n; K PI = k ey i nd ic at or o f pe rf or - m an ce ; M IS L E = M ar in e In fo rm at io n fo r Sa fe ty a nd L aw E nf or ce m en t d at ab as e; N V IC = N av ig at io n an d V es se l I ns pe ct io n C ir cu la r; R O = r ec og ni ze d or ga ni za ti on ; SM S = sa fe ty m an ag em en t sy st em .
BUILDING AND SUSTAINING A SAFETY PARTNERSHIP 125 fulfillment of its role but within the limits of its authorities and capabilities. However, the figure also shows how the Coast Guardâs progress in certain other areas has lagged. Minimal progress has been made in improving the completeness, accuracy, and accessibility of vessel records and in developing a marine inspector workforce with proficiency in observing and assessing SMS compliance and the capacity to coordinate and communicate effec- tively with RO surveyors. These lagging areas, in turn, have made it more difficult for CVC-4 to develop KPIs, introduce more risk-informed means of prioritizing and designing inspections, and ensure that field inspectors are capable of making observations needed for monitoring and assessing RO performance. While this report has offered several recommendations, as recounted below, for addressing these lagging areas, it does not offer recommenda- tions on how the Coast Guard can mobilize the many organizational units whose roles will be critical to bolstering the CVC-4âs efforts to support and oversee the ACP and ROs. The Coast Guard faces many competing demands that it must prioritize for its Mission Support units such as IT, Human Resources, and Force Readiness. The committee did not examine all of these demands. It is incumbent on the Coast Guard to make appro- priate choices in recognition of these demands, including the interest in making more comprehensive and sustained progress in supporting and overseeing ROs. Although unable to advise the Coast Guard on these broader matters, the committee nevertheless observes that the successful creation of a Flag-State Control Division has been a necessary but still insufficient organizational response. DATA AND ANALYTIC SYSTEMS The committee concludes in Chapter 4 that the Coast Guardâs progress to- ward a more data-driven and risk-based approach to verifying compliance and overseeing the performance of ROs has not kept pace with the Coast Guardâs strides in establishing needed organizational structures, policies, and procedures. The committee found that the Coast Guardâs Marine Infor- mation for Safety and Law Enforcement (MISLE) data system is poorly suited to supporting vessel compliance verifications by marine inspectors and RO surveyors as well as Coast Guard oversight of ROs. The data systemâs intended uses are too varied, its design and structure are too out- moded, its records are too incomplete and unreliable, and its access is too restricted. Plans to upgrade or replace the data system are in their infancy and cannot be relied on as either near- or medium-term solutions. Even if a replacement system is created, it is uncertain whether it could permit the needed integration of RO data and permit external access due to data protection and security requirements.
126 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs In the near term, the Coast Guard has little choice but to use the infor- mation in MISLE along with any other relevant data it can obtain from ROs and other sources (such as foreign port-state control inspection data) for the purposes of regulatory compliance verification and RO oversight. However, looking further outâover the next 5 yearsâthere is a greater opportunity for the Coast Guard to collaborate with ROs to create a data base external to MISLE that is focused on the modest-size fleet of vessels that use ROs, including the fewer than 500 ships in the ACP fleet and the fewer than 75 ships in the Maritime Security Program (MSP) Select fleet. Although a data system to fully replace MISLE is on the distant horizon, it holds the great- est promise to support the Coast Guardâs interest in more data-driven and risk-based approaches for vessel compliance verification and RO oversight. Although characterized as key indicators of RO performance (or KPIs), the statistics and metrics that are now publicly reported by the Coast Guard have limited relevance to RO performance or regulatory compliance by the ACP fleet. More relevant and focused KPIs are required and may need to be developed with the assistance of, and information from, ROs and ves- sel owners. In considering the Coast Guardâs use of risk-based approaches for monitoring and assessing RO performance, the Coast Guard stratifies vessels in the ACP fleet on the basis of risk factors to inform the frequency and scope of oversight examinations; however, the need for manual data gathering and input has hindered the timely development and regular use of more sophisticated risk-based models. Absent better data systems and tools for data extraction and analysis, the Coast Guardâs intentions to be more risk based and data driven are not likely to be fulfilled. The following four recommendations pertaining to data, metrics, and risk-based tools are offered with the needs, constraints, and time dimen- sions identified above: Recommendation 1: In the near term, the Coast Guard should collaborate with ROs and vessel owners to develop and execute a plan to share and validate information for the purpose of ensuring that records derived from MISLE of vessels and vessel owners who use RO services are complete, accurate, and current with respect to compliance history. The augmented records should be scrubbed of sensitive information and extracted from MISLE so they can be made available to RO surveyors and auditors in addi tion to marine inspectors. The data set should also be structured to meet CVC-4âs need for calculat- ing specified KPIs, performing risk-based profiling of vessels and ROs, and enabling other data analyses for oversight purposes. Additional data set filtering could enable access and use by vessel owners and the public. Because of the relatively small number of ACP and MSP Select vessels, the manual effort required to correct errors and omissions in their MISLE
BUILDING AND SUSTAINING A SAFETY PARTNERSHIP 127 records and to add supplemental fields should not be formidable. However, it would be desirable for the Coast Guard to ensure that information from the Marine Safety Centerâs plan reviews is incorporatedâas this informa- tion does not currently reside in MISLE. For a relatively small fleet that does not change much from year to year, one would expect that only a modest amount of effort would be required to maintain this extracted data to ensure that it is up to date. Recommendation 2: While collaborating with ROs and vessel owners on means of supplementing, validating, and enabling greater access to relevant MISLE records, the Coast Guard and ROs should work together on the development of KPIs that are most relevant to monitoring and overseeing the performance of ROs. Although persistent shortcomings in MISLE-derived data will undoubtedly limit the quality of the indicators that can be developed, such collabora- tion will offer insight into the kinds of data and data system capabilities that will be needed for the design and functioning of a new stand-alone oversight database. One would expect that measures of outcomes, such as from casualty and pollution records, would be among the suite of KPIs considered, and that some metrics of this type could potentially be developed right away using information already available in Coast Guard and RO databases. Col- laborative thinking about KPIs that serve as leading indicators would also be desirable. Even if current data do not allow for their development, this thinking would help inform the planning of a new data system. Recommendation 3: Congress should resource the development and imple- mentation of a stand-alone data system, fully external to MISLE, that is exclusive to the purpose of supporting compliance verification and RO performance and oversight. ROs should be engaged during the databaseâs planningâsuch as through a Coast Guard and RO database/information technology working groupâto ensure that the databaseâs design, elements, and functional capabilities align with the needs of Coast Guard inspectors, other marine safety personnel, and RO surveyors and auditors. Because the data set recommended aboveâconsisting of mostly MISLE augmentationsâis a short-term fix, it will be important for efforts to get under way to introduce this more functional, stand-alone data system as soon as possible. For this external data system to support compliance verification and RO oversight, it would need an array of features that would serve the purposes of the Coast Guard, ROs, vessel companies, and the public, as discussed in Chapter 4. The data would need to be gathered from mul- tiple sources, both internal and external to the Coast Guard, and would
128 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs need be kept current and regularly validated for accuracy. The database should be designed to facilitate data exchange, ensure data quality, and reduce the need for manual data entry. It would need access features that enable the Coast Guard, ROs, and vessel companies to push or pull data to or from the database between their respective data systems and sources. The databaseâs architecture, therefore, would need to facilitate data shar- ing, inte gration, and analysis and be readily searchable by field inspectors and RO surveyors and auditors. Ensuring that the types of inspection and audit findings, deficiencies, and nonconformities are recorded in a search- able format would help meet CVC-4âs need to calculate more insightful KPIs, perform risk-based targeting of vessels and companies, and develop data tools for oversight purposes. By making these data available, the Coast Guard could encourage external analyses, including scholarly research, that can inform KPIs and risk-based methods. To support such external analyses and assessments, the recommended database should also have a public- facing version with appropriate search capabilities and filters. Recommendation 4: Although it may take many years to bring about, the replacement of MISLE with a new, modernized data system should be a high priority for the Coast Guard to more fully support the work of marine inspectors and ROs and to monitor and oversee their performance. Whether the new system replaces, incorporates, or feeds into and from the external data system recommended above, it will be important that the compliance verification, performance monitoring, and analytic needs of marine inspectors, ROs, TPO coordinators, and CVC-4 are met. Public access, with appropriate protections and filters, should be another specified feature to enable external analysis and ensure more transparency about vessel compliance and RO performance levels. During planning and development of MISLEâs replacement data system, high priority should be given to ensuring that its architecture facilitates data sharing, integration, and analysis among the Coast Guard, ROs, and vessel companies. The efforts of the International Maritime Organization to develop an international standard for data formats, exchanges, and har- monization in international shipping, as well as International Association of Classification Societiesâ development of a unified data exchange format for surveys and audits, should be consulted as models for the systemâs elec- tronic data interchange and sharing. INSPECTOR RESOURCES, TRAINING, AND COORDINATION The El Faro investigations raised concerns about the guidance and resources available to Coast Guard inspectors to conduct high-quality inspections and examinations of vessels in the ACP that use ROs, about shortcomings in
BUILDING AND SUSTAINING A SAFETY PARTNERSHIP 129 inspector competencies and experience levels for this purpose, and about the lack of marine safety personnel charged with, and capable of, oversee- ing ACP compliance and RO performance generally. The Coast Guard has taken important steps to address these concerns, including the introduction of new work instructions and tools (e.g., a mobile app for inspectors), new training courses with relevance to ACP vessels and third-party oversight, and the creation of CVC-4 and TPO coordinators. Nevertheless, needs and opportunities remain for the Coast Guard to further strengthen the performance and capabilities of its marine safety workforce by: â¢ Actively monitoring the competencies that marine inspectors have and need for conducting vessel inspections and oversight exami- nations in order to determine where further improvements are warranted; â¢ Verifying that Coast Guard guidance on the career progression paths for Operations Ashore Prevention Officers can be pursued without undue impediment, is indeed being pursued by sufficient numbers of junior officers, and aligns with the goal of ensuring that mastery of marine inspection specialties provides sufficient profile and opportunities for assignments that can lead to command and leadership positions such as Officer in Charge, Marine Inspections (OCMI); and â¢ Ensuring that all marine inspectors, and particularly senior inspec- tors, have sufficient knowledge of SMS principles and purposes to make observations about whether vessel and company SMS plans are being followed. SMS training for senior inspectors, including training on the process and principles of SMS audits, would cre- ate a valuable skill set that could make this career path even more desirable. On the basis of these findings, the committee recommends the following: Recommendation 5: The Coast Guard should consider establishing a standardization team, modeled after similar teams in other Coast Guard domains, that visits marine inspection field units on a regular basis to assess inspector competencies, the consistency in following work instructions and protocols, and the quality of inspections. The team, whose role should also be to provide real-time, constructive feed- back to inspectors and to inform Coast Guard inspector training programs, could be created through augmentation of the Coast Guardâs traveling staff of senior marine inspectors.
130 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs Recommendation 6: The Coast Guard should review its current career path progression guidance for Operations Ashore Prevention Officers, which was introduced before the El Faro investigations, with an eye to whether the guidance is being followed by sufficient numbers of junior officers, provides opportunities to master the marine inspection specialties, and ensures that mastery of those specialties provides ample career advancement opportuni- ties in the prevention field, including relevant leadership positions such as OCMI. While the Coast Guard has acknowledged the importance of ensuring that OCMIs have marine inspection expertise, it is an imperative for assign- ments in the countryâs largest commercial and feeder ports. To meet this imperative, the Coast Guard must make sure marine inspection career pathways exist that are attractive and are being pursued by officers quali- fied for these assignments. Recommendation 7: The Coast Guard should ensure that all marine in- spectors have sufficient understanding of the purpose and components of an SMS and how adherence to it should be evident during an inspec- tion. Senior inspectors should have a strong understanding of how an RO conducts an SMS compliance audit to allow them to know when deficien- cies and nonconformities observed during vessel inspections and oversight exami nations may be indicative of substandard RO performance and war- rant referral to the Flag-State Control Division (CVC-4) and third-party organization coordinators. Because the SMS audit function is a critically important role of the RO, the Coast Guardâs oversight of it must be robust and comprehensive, starting with ensuring that field inspectors have sufficient awareness and under- standing to observe compliance firsthand. COOPERATION, COMMUNICATIONS, TRANSPARENCY, AND CONTINUOUS LEARNING To its credit, the Coast Guard has created a strong framework for RO monitoring and oversight through a dedicated oversight unit and new policies and procedures. However, the committee also finds that the Coast Guardâs efforts to improve its data systems, metrics, and analytic tools have not kept pace, nor have its efforts to build the requisite capabilities and competencies of its marine inspector workforce. Slow progress in address- ing these shortcomings will hinder effective implementation. While poised to address some of the shortcomings (e.g., by offering pending training courses), the Coast Guard will need to be creative in addressing others (e.g., data) while more permanent solutions are being sought. The steps recom- mended above, in the committeeâs view, are representative of the kinds of
BUILDING AND SUSTAINING A SAFETY PARTNERSHIP 131 measures the Coast Guard should pursue to capitalize on the progress that has already been made. In thinking about the end goal of positively impacting vessel compli- ance and safetyâwhich Congress has set as the measure of effectivenessâ the committee also believes it will be important for the Coast Guard to ensure that its relationship with the ROs involves more than performance monitoring and oversight. When the ACP was created more than 20 years ago, among its key selling points was that it would not only relieve the Coast Guard of redundant inspection responsibilities but that it would leverage a well-trained and experienced RO workforce to bring about even higher levels of vessel compliance and safety. In turn, the Coast Guard could concentrate its inspection resources in other higher-risk areas to provide additional safety dividends. The strengthening of that partnership should therefore be a foremost aim of the oversight program and inculcate all efforts to support and improve it. Enforcement of compliance has been a hallmark of regulatory pro- grams, but one that has come under scrutiny in recent years as modern regulators view their function as part of a broader responsibility to prompt and assist industry in achieving the end goal of safe and environmentally sound operations through the application of a range of tools and methods at the regulatorâs disposal. For instance, regulators who view safety advo- cacy as a fundamental obligation are more likely to stress the importance of sharing information across entities, transparency through open dialogue and communications, and continuous learning that includes being intro- spective about the regulatorâs own blind spots and deficiencies that may be contributing to substandard performance by the regulated entity, or in this case the RO. The El Faro investigations revealed how the Coast Guard had, in some important respects, failed to maintain its end of a partnership arrangement with ROsâfor instance, by eliminating the position of liaison officers, not keeping U.S. Supplements up to date and well focused on critical sys- tems, and failing to develop an inspector workforce capable of augmenting and complementing, rather than simply checking on, the work of the RO surveyors. Spurred by the findings from the El Faro investigations and re- quirements of Congress, and through its own self-examinations, the Coast Guard has taken many steps to strengthen its support for ROs along with its monitoring and oversight. The single U.S. Supplement, reestablishment of liaison arrangements with ROs, and CVC-4âs convening of annual con- ferences with ROs are notable examples of these steps. At the same time, the committee found limited evidence of Coast Guard progress in ensuring that marine inspectors and RO surveyors can, and do, readily communicate and share data on their own inspections and on the compliance histories of the vessels. This shortcoming can compromise their
132 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs ability to work as a team and needs to be addressed. The mostly one-way access to complete vessel records, whereby the Coast Guard inspectors can access RO databases but RO surveyors cannot access all relevant Coast Guard data, is a particular problem that has not been rectified. It was iden- tified by El Faro investigators and is the subject of recommendations in this report. The Coast Guardâs efforts to develop and make use of key indicators of RO performance have been hampered by data inadequacies stemming in part from a lack of sharing by all parties, and have been made worse by data systems that do not integrate. Where it has sought to develop perfor- mance metrics, the Coast Guard has chosen to report only some of them publicly for reasons that are not clear. Efforts to develop risk-informed methods for designing and focusing compliance verification and RO over- sight activities have proven to be so labor intensive and lacking in fidelity that their utility has been limited. Until the improvements to data systems are made, as recommended in this report, these problems are likely to per- sist. Yet, when they are resolved, it will be important for the Coast Guard to make its KPIs and risk-informed methods public. Such transparency is vital to not only ensuring that all parties can consult and advise on them but also to allow others, including the scholarly community, to replicate the underlying analyses and to conduct independent analyses. Transparency is vital to harnessing the capacity of all parties to drive continual improve- ments in the metrics and tools needed to ensure that resources are devoted to mitigating the highest consequence risks. In cases where it has made significant progress in introducing oversight mechanisms, such as in creating work instructions for verifying that ROs are properly and vigilantly auditing vessel and company SMS plans, the Coast Guard may want to take stock in whether these mechanisms are designed and being implemented in a manner that reinforces the safety partnership. For instance, when it reviews evidence of substandard per- formance and conducts audits of ROs, the Coast Guard could see this as an opportunity to consider the effectiveness of its own efforts to support high-quality performance, thereby reinforcing a culture of learning and continual improvement by the ROs, vessel operators, and the Coast Guard itself. Indeed, all monitoring and oversight activities will present opportu- nities for the Coast Guard to be more holistic in the thinking about where improvements are needed and how they should be made. Having several years of experience with the implementation of its new organizational and procedural framework for RO oversight, the Coast Guard can now take stock in whether its elements are designed and being implemented in a manner that reinforces a safety partnership. For instance, it can reflect on whether its reviews of RO survey and audit performance, including its own audits of ROs, are shedding light on the effectiveness of its own efforts to support high-quality RO performance, thereby reinforcing
BUILDING AND SUSTAINING A SAFETY PARTNERSHIP 133 a culture of learning and continual improvement by not only the ROs and vessel operators, but also the Coast Guard itself. Indeed, all monitoring and oversight activities will present opportunities for the Coast Guard to be more introspective and comprehensive in thinking about where improve- ments are needed and how they can be made. With this interest in mind, the committee recommends the following: Recommendation 8: With the intent of fostering continuous improvement and greater transparency, the Coast Guard should build on its current practice of conferring with ROs, shipping companies, and other flag-state regimes. Regular, periodic meetings with these groups should be arranged to communicate ideas and concerns and, where practical, share approaches to KPI assessment, flag-state inspections, and RO oversight. Ultimate responsibility for safety rests with the vessel owner and cannot be delegated. However, high-quality inspections and audits are critical to achieve desired safety outcomes. The committeeâs overall impression is that the Coast Guardâs commitment to meeting these needs has been commend- able, producing a well-planned and promptly executed response. For this commitment to be sustained and the response made more comprehensive and complete, the Coast Guard will need to leverage other parts of its enter prise, from human resources to IT. It will also need to partner and collaborate in the many and varied ways recommended above. Doing so will undoubtedly require a devotion of resources that the study committee is not in a position to estimate, but that Coast Guard leadership and Congress will need to take into account.